Symptom Clusters After Esophageal Cancer Surgery Have Prognostic Value

Patients who exhibited certain clusters of symptoms after undergoing surgery for esophageal cancer were at an increased risk for mortality, according to the results of a prospective Swedish cohort study. Specifically, symptoms associated with reflux or cough, or with eating difficulties conferred an increased risk for mortality.

“Since it is well known that these patients suffer from a multitude of symptoms as a consequence of their treatment we wanted to dig deeper and see whether we could find a pattern of symptoms which could have implications for outcomes,” said study author Anna Wikman, PhD, of the unit of upper gastrointestinal research at Karolinska Institute, Sweden. “Symptom clustering has been studied in other cancer populations so we were expecting to see some clustering of symptoms, but we were indeed surprised to find that the presence of these symptom clusters was associated with poorer survival, even after adjusting the analyses for other known prognostic factors.” 

Wikman and colleagues examined outcomes among 402 surgically treated patients with esophageal cancer enrolled between 2001 and 2005. The patients had postsurgical cancer-specific symptoms assessed using a quality-of-life questionnaire 6 months after surgery. Men aged 60 to 74 years made up the majority of patients. The results of the study were published in Cancer.

The researchers were able to identify three distinct symptom clusters. In order to be included in the cluster, patients had to experience at least 50% of the symptoms in the cluster. Thirty percent of patients had a cluster identified as a fatigue/pain cluster. Patients experienced general and esophageal pain, fatigue, insomnia, and dyspnea.

The second identified cluster was reflux/cough, which was reported by 27% of patients. This cluster was characterized by symptoms of dry mouth, problems with taste, coughing, and reflux.

The third cluster was eating difficulties, defined as symptoms related to eating, such as appetite loss, dysphagia, eating difficulties, and nausea/vomiting. Twenty-eight percent of patients reported eating difficulties.

“These results show that clinicians should be aware that the post-operative symptoms experienced by these patients are likely to present in specific symptom clusters, and should therefore be on the lookout for patients who report combinations of symptoms, such as those present in the symptom clusters found in this analysis,” Wikman said. “However, many patients do not report problematic symptoms to their doctor and therefore it is important for clinicians to be more active in asking patients about their symptoms.”

Wikman and colleagues found baseline characteristics that were associated with each symptom cluster. Patients with higher tumor stage, squamous cell carcinoma, more complications, and younger age were significantly more likely to have the fatigue/pain cluster. Squamous cell carcinoma and more complications were also associated with the presence of the reflux/cough cluster, and higher tumor stage and more complications were associated with the eating difficulties cluster.

Of the patients on study, 31% were alive at 5 years. Data indicated that reflux/cough (HR = 1.43; 95% CI, 1.08-1.89) and eating difficulties (HR = 1.41; 95% CI, 1.06-1.87) clusters were significantly associated with an increased risk of mortality.

“Since the presence of these symptom clusters confer an increased mortality risk it might be possible that addressing these symptoms early on might have an impact on reducing this risk,” Wikman said. “A more intensive follow-up of those patients at risk of these symptom clusters may be a first step.”